Surgical Challenges in Infective Endocarditis: State of the Art.

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Prognostic Implication of Preoperative Anemia in Redo Cardiac Surgery: A Single-Center Propensity-Matched Analysis.

Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known about its prognostic value in the setting of redo procedure. A retrospective, observational cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020. The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. Selection bias was assessed with the propensity-adjustment method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and nonanemic groups emerged in the risk for postoperative stroke (0.6% vs. 4.4%, p = 0.023), postoperative renal dysfunction (29.7% vs. 15.6%, p = 0.001), a need for prolonged ventilation (18.1% vs. 7.2%, p = 0.002), and high-dosage inotropes (53.1% vs. 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2 ± 15.9 vs. 4.3 ± 5.4 days, p = 0.003 and 18.8 ± 17.4 vs. 14.9 ± 11.1, p = 0.012). After propensity matching (145 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke, and the need for high-dosage inotrope cardiac morbidity. Preoperative anemia is significantly associated with acute kidney injury, stroke, and the need for high-dosage inotropes in patients referred for redo procedures.

Can prosthesis type influence the recurrence of infective endocarditis after surgery for native valve endocarditis? A propensity weighted comparison.

OBJECTIVES: Our goal was to investigate whether the incidence of valve-related adverse events might be different depending on the valve substitute after valve replacement for left-sided native valve endocarditis. METHODS: We assessed the long-term freedom from recurrence, reoperation and survival of 395 patients who had valve replacements for native valve endocarditis (314 mechanical vs 81 biological). Age <18 years, reoperation, prosthetic endocarditis, right valve involvement, valve repair and homograft implants were the main exclusion criteria. The balance between the 2 groups was addressed by weighting the results on the inverse of the propensity score. RESULTS: After inverse probability of treatment weighting (IPTW), freedom from recurrence of infective endocarditis was not significantly different (mechanical 84.1 ± 3.2% vs 50.6 ± 21.7%; P = 0.29) nor was freedom from reoperation different (mechanical 85.7 ± 3.1% vs biological 50.9 ± 21.9%; P = 0.29). Excluding competing deaths, patients receiving a bioprosthesis had a similar subdistribution hazard of the above end points compared to recipients of a mechanical valve [recurrence IPTW: hazard ratio (HR) 1.631, 95% confidence interval (CI) 0.756-3.516; P = 0.21; reoperation IPTW-HR 1.737, 95% CI 0.780-3.870; P = 0.18]. Mechanical valves were associated with improved long-term survival (34.9 ± 5.8% vs 10.5 ± 7.4% at 30 years; P = 0.0009; in particular: aortic valve subgroup 41.6 ± 9.3% vs 10.1 ± 8.2%; P < 0.0001), although the hazard of cardiovascular mortality did not favour either valve type (IPTW: HR 1.361, 95% CI 0.771-2.404; P = 0.29). CONCLUSIONS: Our analysis showed a clinical trend in favour of mechanical valves as valve substitutes for native valve endocarditis, especially in the aortic position. In view of long-term freedom from adverse events, the choice of the valve type should be tailored according to patient characteristics and specific clinical conditions.

Implications of abnormal ascending aorta geometry for risk prediction of acute type A aortic dissection.

OBJECTIVES: Recently, increased length of the ascending aorta has been suggested as a possible risk factor for acute type A aortic dissection (ATAAD). Our goal was to identify measurable aortic geometrical characteristics associated with elongation that could differentiate ATAAD from uncomplicated aortic dilation (>45 mm). METHODS: In angiographic computed tomography scans performed in 180 patients having cardiac surgery, aortic diameters, root length, length of the ascending aorta at both the centreline and the greater curvature (convexity) and the root-ascending (root-asc) angle (that between the root axis and the axis of the ascending tract) and the ascending-arch (asc-arch) angle (that between the axis of the ascending aorta and the arch axis) were measured and compared among 3 patient groups: normal aorta (diameter < 45 mm), dilation/aneurysm (>45 mm) and ATAAD. Correlations between diameters and angles, diameters and lengths and lengths and angles were analysed; multivariable analysis including geometrical factors was performed to identify independent predictors of ATAAD. RESULTS: Both patients with aneurysms and patients with ATAAD showed significantly elongated ascending aortas (P < 0.001 vs normal). However, in the aneurysms, the root-asc angle (136° ± 20° vs 147° ± 17°; P < 0.001) and in ATAAD the asc-arch angle were uniquely narrower than that in the normal aorta (116° ± 11° vs 132° ± 19°; P < 0.001). All patients with an ATAAD had an asc-arch angle ≤130°. Both in patients with ATAAD and in those without ATAAD, narrowing of the asc-arch angle was associated with elongation of the root segment (P < 0.001). In multivariable analysis, the asc-arch angle and the total length of the ascending aorta (root + tubular) were significant predictors of ATAAD. CONCLUSIONS: The asc-arch angle is a promising measurement that could help predict aortic dissection along with aortic diameter and length: further verification is warranted.

Cardiac surgery practice during the COVID-19 outbreak: a regionwide survey.

BACKGROUND: Health systems worldwide have been overburdened by the "COVID-19 surge". Consequently, strategies to remodulate non-COVID medical and surgical care had to be developed. Knowledge of the impact of COVID surge on cardiac surgery practice is mainstem. Present study aims to evaluate the regional practice pattern during lockdown in Campania. METHODS: A multicenter regional observational 26-question survey was conducted, including all adult cardiac surgery units in Campania, Italy, to assess how surgical practice has changed during COVID-19 national lockdown. RESULTS: All centers adopted specific protocols for screening patients and personnel. A significant reduction in the number of dedicated intensive care unit (ICU) beds (-30.0%±38.1%, range: 0-100%) and cardiac operating rooms (-22.2%±26.4%, range: 0-50%) along with personnel relocation to other departments was disclosed (anesthesiologists -5.8%±11.1%, range: 0-33.3%; perfusionists -5.6%±16.7%, range: 0-50%; nurses -4.8%±13.2%, range: 0-40%; cardiologists -3.2%±9.5%, range: 0-28.6%). Cardiac surgeons were never reallocated to other services. Globally, we witnessed dramatically lower adult cardiac surgery case volumes (335 vs. 667 procedures, P<0.001), as institutions and surgeons followed guidelines to curtail non-urgent operations. CONCLUSIONS: This regional survey demonstrates major changes in practice as a response to the COVID-19 pandemic. In this respect, this experience might lead to the development of permanent systems-based plans for future pandemic and may effectively help policy decision making when prioritizing healthcare resource reallocation during and after the pandemic.

Safety of low intensity oral anticoagulant therapy in patients with bileaflet mechanical aortic valve prosthesis: A propensity weighted study.

BACKGROUND: Scarce data are available on the long-term outcomes of different regimens of oral anticoagulation in an all comer population of patients undergoing aortic valve replacement with a bileaflet mechanical heart valve. METHODS: Outcomes of 88 patients discharged with a target INR of 2.0 (LOW-INR) were compared to 147 contemporary patients who have been recommended a target INR of 2.5 (CONV). Primary outcome was the composite of any thromboembolic or haemorrhagic events. Secondary outcomes were the individual components of the primary outcome, cardiovascular mortality and stroke. To reduce selection bias, a propensity weighted analysis was performed. RESULTS: After inverse probability of treatment weighting, the primary endpoint occurred in 0.7% of patient in the LOW-INR group and in 7.0% in the CONV group (p = .0255). Linearized event rate were significantly lower in the LOW-INR group (primary endpoint: rate difference - 12.0 per 1000 patient/years, p = .0052; haemorrhage: -5.8 per 1000 patient/years, p = .0330; neurological events: -7.6 per 1000 patient/years, p = .0140). Conventional target INR was associated with an increased hazard of the composite endpoint (HR 11.193, 95% CI 1.424-88.003, p = .0217). CONCLUSIONS: Lowering the intensity of oral anticoagulation resulted in a relevant clinical benefit of reduced rates of haemorrhagic and neurological adverse events in the mid-term follow-up. This report confirms the safety profile of the low INR regimen in an all comer population undergoing aortic valve replacement with an Abbott mechanical valve.